4 Things HMO Insurance Won’t Say

It feels weird making a new blog post after almost three months of not writing one. Sorry, but my mind sometimes short circuits and does not come up with any useful information. As you know, this is not my job and I just do this during my free time.  But I still hope you can get something from this little blog of mine. So before you yawn and hit the delete button, those of you with HMO insurance might want to know some things these HMOs won’t tell you.

  I recently had a patient who came in with her family. They reminded me of Goldilocks and the Three Bears where one was too large, one was too small, and one was just right. The Goldilocks look-alike was the mother.  The father and kids all look like bears.  (I pity the kids. Hehe. JokeJ). Anyway, the mother needed an operation for a torn knee ligament. She told me they got a Health Maintenance Organization (HMO) insurance and this will take care of her operation. At first, she was smiling and ready to schedule the surgery.  But when she realized that there were things that she didn’t expect from the HMO insurance, her face suddenly changed like that of a child whose lollipop was taken by another person.

    From experience, here are some things your HMO won’t tell you when you avail of the HMO insurance, so take note and be prepared to ask so you won’t feel disappointed.

          1.      They will not tell you that your medical insurance is not always enough for your surgery.

HMOs usually have a maximum benefit limit (MBL) for each disease and if you have used any of these benefits before, such as consultations or lab exams, there will be deductions from your total benefit. Also, implants are usually not covered. So if you need surgery for a fractured hip and you were advised by your orthopedic doctor that you need implants to fix or replace them, chances are, you need to churn out money for the implants. In some cases, these implants are not cheap at all.

This particular patient of mine even had a heated argument with the insurance agent because she felt that the amount being deducted from her salary was big enough to cover her surgery.

                                 

       2.       They will not tell you that your preferred doctor and hospital are not always accredited with your HMO insurance.

 There are even instances that your favorite doctor may be accredited in his or her clinic, but not accredited in the hospital.  So be sure to inquire about this. 

          3.       They will not tell you that they will pay your doctor with a discounted or “negotiated” rate after 3 months, 6 months, 1 year, or worse, never at all. Then, they will make all sort of excuses such as documents not signed, lost documents, etc, despite having a contract with us, doctors, stating that they will pay within 30 days.  The problem with us, doctors, is that we are generally poor negotiators since most of us are not businessmen, and we end up providing quality health services without being paid or paid on time, while making you, the patient, believe otherwise. 

For most patients, this does not really concern you, as long as you get the appropriate treatment.  That’s all right. But I just want to inform you why some doctors do not accept or ask you the option of paying more than what the insurance company is willing to pay us, before we agree to operate on you.  “Tinitipid nila kami, sobra.”

          4.       They will not tell you that you need to have Philhealth coverage, or else, you will need to pay the amount what Philhealth normally pays for.  From what I know, Philhealth pays 20-30% of the total hospital costs.

For employed individuals, this is usually not a problem since Philhealth contributions are mandatory by law when you’re employed, this being automatically deducted from your salary. You just need to bring the proof of contributions prior to surgery, either from Philhealth office or from your HR department. So make sure you or your employer is up-to-date with your Philhealth contribution, and that you have clearly stated in your Philhealth Membership form, who your dependents are.  For self-employed individuals, you have to make sure you pay the Philhealth contributions yourself, or ask someone to do it for you if you don’t have the time. The last time I checked, you should have contributed at least 6 months prior to your scheduled surgery to avail of Philhealth benefits.

When I was just starting my private practice a few years ago, my daughter was confined in the hospital. I thought I can use my Philhealth. But it turned out I had missed contributions the past months before her confinement because I was abroad undergoing fellowship training.  So too bad I wasn’t able to get my Philhealth benefits then. 

It is also good to ask your surgeon if the medical facility where you will have your surgery is Philhealth-accredited.  With the popularity of outpatient or ambulatory surgery centers, like those in the malls, some may or are not yet Philhealth-accredited.  In such cases, you will not be able to avail of your Philhealth benefits.

It is imperative that you read and understand your medical coverage and benefits, and have the surgery or procedure approved first by your HMO, especially for elective or non-emergency cases, before you decide to get admitted and go under the knife. You may end up paying more than what you expected and feel unprepared financially just like what happened to my patient.

8 Ways to Decrease Health Expenses

This post is not directly related to anything orthopedics. But anything related to my practice or medicine in general, I said I will discuss from time to time. And since personal finance has been one of my interests also, I found a perfect way to combine health or medicine, and financial management in one post.

Now to illustrate my point, one of the highest expenses you can have in your lifetime is health expenses. Health expenses can really drain your finances, and it seems like health costs always go up, no matter what you do, who’s in charge, or what laws are passed. Just like costs of basic goods, health costs increase with inflation.  In order to save money on health expenses,  there are a few things we can do:

1.      Keep and stay healthy.

This is probably the most important thing. You have more health expenses if you can’t lose your fat, or eat too much. Exercise, eat a balanced diet, and try to take time for relaxation and stress relief. You will need fewer doctor’s visits and will have fewer illnesses. And, while nothing can protect you completely, good health habits in general can lead to better disease management and protection, and less of a need for using health care services.

    Even doctors get sick.  Even cardiologists suffer heart attacks.  Even orthopedic surgeons can suffer from fractures. No one is immune from all diseases, especially as you grow old.

2.      Keep an emergency fund for health expenses 

You will never know when emergencies will occur.  And if such scenario happens (knock on wood), how do you plan to pay for your hospital bills?  By cash, by credit card, by selling your house, or by selling your kidneys?  In fact, as an orthopedic surgeon dealing with accidents or injuries and fractures almost daily, I see patients who are hard-pressed to find money for their medical and surgical care, even those with medical insurance.  It is heart-breaking to see patients crying in front of me because they can’t afford the treatment proposed. Do we want to be like them?

Bear in mind that emergency fund is money you can readily get without having to liquidate your long-term investments.  Some recommend a 6-month worth of monthly expenses as your emergency fund.  This can be placed in savings, time deposit accounts or even money market funds, where you can readily liquidate them.

Some believe that their credit cards are a form of emergency fund.  Sure, you can use them especially when required down payment by the hospital.  But make sure you pay the whole bill at the end of the billing period as credit cards have the highest interest rate known to man (next to the “Bumbay’s” 5-6).

3.      Contribute to Philhealth 

     Philhealth is our government’s medical insurance.  It will not pay for everything on your hospital bills. But a 20-30% reduction on your medical bills is not bad, for only a P100 or P200 monthly contribution. So unless you’re a beggar roaming in the streets, you can afford to contribute to Philhealth. If you are employed, this is automatically deducted from your salary.  But if you are self-employed, you need to pay personally.  Be sure your payment is up to date.

4.      Get a health insurance 

        Any coverage is better than no coverage. There are different health insurances available, but some are quite expensive.   Health Maintenance Organizations (HMOs) and life insurances provide some health benefits, depending on the type. They are appropriate in some situations, but not in some. Just remember to understand your coverage carefully.  Many patients have incurred large medical bills, only to find that a large portion of the bill is not covered by insurance, due to exclusions and limits. The actual coverage under health insurance can be quite complicated to understand, so be sure to read your policy and clarify things with your agent.

Also, if you already have a health insurance, check if you are paying for something you don’t really need.  You might be surprised that you have coverage for maternity benefits when you are already menopausal!  Cut your benefits and you may be paying a smaller premium.

5.      Buy generic 

      No study have really proven the superiority of branded medicines to generic ones.  But if you’re really doubtful of generic medicines, discuss with your trusted physician.

6.      Use your discount cards  

     The senior citizen cards are the most useful discount cards that can be used here in our country. If you’re a senior citizen, make sure you get one and bring them everytime you purchase your medicines.  And don’t forget to bring your doctor’s prescription and booklet as pharmacies usually require these before they give you the discount. I once saw an elderly patient who got so stressed at a pharmacy counter because she forgot her prescription pad and the pharmacist didn’t want to give her the SC discount. She was arguing relentlessly I thought she would collapse.  Don’t be like her.

7.      Ask your doctors if their fees are negotiable 

       This may be awkward, but it never hurts to ask.  I may be speaking only for myself, but as a doctor, I find giving patients discount for PF is a good way to build relationships.  Some patients really can’t afford, so there’s really nothing we can do about it.  Many of us will be happy to be paid today at reduced fees rather than wait 90-180 days for the insurance company to pay us with nearly the same “negotiated” rate.

8.      Ask help from hospital’s social service

       This is not applicable to everybody, because those who are qualified are the ones who can’t really afford. The qualifications are stiff, but you can at least try.  Even the big hospitals are required to offer a service or charity program. You can also try to get help from PCSO or the Philippine Charity Sweepstakes Office.

Take Home Message

  

      We will all get sick during our lifetime.  And it is imperative that we should have a plan on how to pay and subsequently decrease our health expenses, or we can go bankrupt with even with just one major disease or accident.  This will ultimately help us attain financial success in life.

Can you think of other ways to decrease your health expenses?